Bariatric Surgery: Options and Complications Jennifer Choi, MD, - PowerPoint PPT Presentation

Bariatric Surgery: Options and Complications Jennifer Choi, MD, FACS May 6, 2015

IU Health Post-Op Modification of Co-Morbidities Co-Morbidity Total Improved/Resolved Percentages Back Pain 76% Depression 25% Diabetes Mellitus 83% Esophageal Reflux 62% Hyperlipidemia 61% Hypertension 75% Obstructive Sleep Apnea 49%

What are the surgical options? • Adjustable Gastric Band (LAGB) • Sleeve Gastrectomy (LSG) • Roux en Y Gastric Bypass (LRYGBP) • Duodenal Switch (BPD-DS)

Surgical Basics: LAGB • OR Time approximately 1 hour • Frequently outpatient stay • No malabsorption • Best for lower BMI, exercise ability • Expect diet to be ½-1 cup per meal • Fill (increase saline in band) when inadequate weight loss, early hunger between meals, larger portion sizes

Surgical Basics: LSG Advantages • 2/3 of stomach removed • Reduced stomach capacity • No adjustments • OR Time approximately 1-2 hours • Hospital stay = 1 - 2 days Disadvantages: • Potential for leak (at GE junction) • Nutritional supplements required • Insurance coverage varies

Surgical Basics: LRYGBP Advantages: • Greater excess weight loss • Better long-term results • Decreased hunger (feeling full) • OR Time 2-3 Hours • Hospital Stay 1-2 Days Disadvantages: • More complex operation • Potential for leak • Nutrient supplements required

Surgical Basics: BPD-DS • Advantages – Greatest weight loss – Malabsorption of calories – Comorbidity resolution • Disadvantages – Most complex operation – Malabsorption of nutrients – Highest risk for complications – Highest risk for nutritional deficits

What operation to choose? Patient choice with physician input • Most patients have an idea of what they want, but… • Physician input and expertise is a must. – BMI – no band if BMI>50 – GERD – prefer RYGBP if severe. – Prior surgical hx – IBD – prefer sleeve gastrectomy – Severe osteoporosis – prefer LSG – Tobacco use = NO SURGERY

Band Complications • >30% of bands have required reoperation or removal • Band Occlusion • Band Slip – maladaptive eating, GERD, pain • Band Erosion – Port site infection, wt regain • Chronic complications – GERD, Esophageal dilation, failure

The Adjustable Gastric Band • 45 yo female POD#1 s/p R knee arthroscopy with severe PONV; hx Realize Band 3 years ago, now with wretching, foaming at mouth • Other possible symptoms – Severe Heartburn – Regurgitation – Intolerance to liquids – Chest Pain

• Remove fluid (safest to remove all), liquid diet x 48 hours, fu with bariatric surgeon

45 yo female with severe epigastric and left shoulder pain, difficulty swallowing, Temp 39.1

Band Erosion/Port Infection • Rarely an emergency – Wt regain • Can be removed endoscopically • Consider transgastric removal if emergent.

RYGBP Complications • Small Bowel Obstruction – Internal hernia until proven otherwise • Marginal Ulcer – SMOKING, NSAIDS Acid-related – Bleeding – Perforation • Nutritional Issues – Vitamins – MTV C Fe, B12, Calcium Citrate • Gallstone disease – Actigall, cholecystectomy when indicated

SBO = Internal Hernia • Mesenteric Defects – Peterson’s Defect – Jejunojejunostomy • Symptoms – may be subtle – Left upper quadrant pain – Dry Heaves, bloating – Vomiting • CT Findings – Mesenteric swirl, Dilated small bowel • Low index of suspicion

Marginal Ulcer • Symptoms – severe epigastric pain, esp with eating. • Etiology – NSAIDS – TOBACCO USE – H Pylori • EGD, BID PPI (open capsule), Carafate • Perforation – Graham patch

Sleeve Gastrectomy Complications • Leaks can be delayed (weeks) • Stricture at Incisura angularis • Prolonged postop nausea • Vitamin Deficiencies (rare) • Severe GERD

Nutritional Concerns • Usual Daily Vitamin Regimen – Multivitamin with Iron – 1500mg Calcium Citrate – Monthly B12 Injections or weekly sublingual tabs • B12, Fe Deficiency – anemias • Calcium/Vit D – 2’ Hyperparathyroidism, Osteoporosis • Protein – encourage 60-80 grams/day • Micronutrient concerns – Vit A, Vit K, Thiamine, Zinc, Selenium • Severe protein calorie malnutrition and fat soluble vitamin deficiency with BPD-DS

Bariatrics Complications

Results

Reduction in BMI by Surgery Annals of Surgery. 254(3):410-422, September 2011.

Diabetes Annals of Surgery. 254(3):410-422, September 2011.

Hypertension Annals of Surgery. 254(3):410-422, September 2011.

Sleep Apnea

Hyperlipidemia

Diabetes and LSG/RYGBP • Resolution and improvement depends on se severity ity and dur uratio tion of diabetes • Many leave hospital with little or no diabetic agents (prior to any weight loss) • GBP Reverses inflammatory state associated with obesity (decreased CRP) and modifies a number of other factors: Ghrehlin, GLP-1, Peptide YY, many others.

Diabetes Perhaps a talk For another day!

Post-Op Modification of Co-Morbidities Co-Morbidity Total Improved/Resolved Percentages Back Pain 76% Depression 25% Diabetes Mellitus 83% Esophageal Reflux 62% Hyperlipidemia 61% Hypertension 75% Obstructive Sleep Apnea 49%